CASE PRESENTATION: A 56 year old male patient presented to an outside hospital with a several month history of constitutional symptoms and was initially diagnosed with acute pancreatitis. He subsequently developed respiratory failure requiring intubation and transfer to our hospital. A bronchoscopy revealed a progressive bloody return indicating DAH. He developed AKI with a peak creatinine of 6.5 mg/dL. Urinalysis showed proteinuria and RBC casts. Antibodies were positive for MPO and p-ANCA. The kidney biopsy was consistent with ANCA associated vasculitis. High dose steroids, rituximab, PLEX, and hemodialysis were initiated with considerable improvement allowing for extubation. However, a few days later he developed acute abdominal distention and respiratory distress requiring re-intubation. An abdominal CT suggested extensive small bowel ischemia. An emergent laparotomy revealed necrotic bowel requiring removal of 60% of the small bowel and an end ileostomy. He was ultimately discharged after a prolonged hospital stay including 2 weeks in the ICU. He required hemodialysis for one month and also needed total parenteral nutrition for short-gut syndrome.